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What are the layers of the pericardium?

Outside to inside:

- Fibrous layer
- Parietal pericardium
- Pericardial cavity
- Visceral pericardium


What are the common causes of acute pericarditis?

- Viral illness
- CT or autoimmune diseases
- Uremia
- Metastatic tumors


What are the common presentations of acute pericarditis?

- Sudden onset chest pain (SEVERE) => sharp
- Chest varies w/ position and breathing => this is NOT the case w/ MI

MI pain is also pressurized than sharp


How do you diagnose acute pericarditis?

- Chest pain varies w/ position, breathing
- Pericardial rub on cardiac exam (comes and goes)
- EKG => diffuse ST elevation
- ECHO => pericardial fluid

There is a response to anti-inflammatory agents (NSAIDs are preferred, also aspirin and *colchicine*)


Where do you see diffuse ST elevation on an EKG?

It's everywhere! at every lead!

- NOT an MI => you'd be dead by now
- think pericarditis


What are the common causes of pericardial effusion?

- Viral/acute idiopathic pericarditis
- Metastatic malignancy
- Uremia
- Autoimmune disease
- Hypothyroidism

Now there's fluid accumulation


How is pericardial effusion best diagnosed?



Describe small pericardial effusions

- W/o high intrapericardial pressure may be asymptomatic
- happens w/ acute trauma (gun shots, stabs)


Describe large pericardial effusions

- Has high intrapericardial pressures
- Causes cardiac tamponade


What is cardiac tamponade?

- Heart is unable to fill appropriately
- Myocardial compression impairs diastolic filling
- Causes by rapidly accumulates moderate sized or large effusions


Describe the clinical presentation of pericardial effusion with tamponade

- Decreased RV diastolic filling during inspiration
- Distended neck veins
- Inspiratory decrease in arterial pressure (15-20 mm drop in systolic pressure) => paradoxical pulse


Why does the BP drop with pericardial tamponade?

- Free wall of RV is unable to expand with each inspiration (b/c of effusion)
- In order to accomodate for increase in blood flow => it pushes septum => LV has a decreased SV


What medication do you not want to give to patients with pericardial tamponade?


-In fact you may want to give them fluid
- A stab wound will already decrease the BP b/c of fluid loss => not enough blood being pumped
- You want to increase BP to ^ blood to the rest of the body
- Diuretics would cause the pt to go into shock


What findings do you expect to see and not see in a chest Xray?

- Enlarged heart
- Non-congested lungs (you would see this only in MI w/ lungs vessels accommodating the heart)


Describe the findings in an ECHO of a pt w/ pericardial tamponade

- Collapse of RA and RV at end-diastole
- Dilation of IVC (does not collapse during inspiration)


What do you expect to see on an EKG of a pt/ with pericardial tamponade?

- Low QRS voltage
- Also sinus tachycardia
- Electrical alternans w/ sinus tachy (every other beat the QRS voltage decreases)


Describe constrictive pericarditis

- Scarring or loss of elasticity of pericardium
- Impaired diastolic filling w/ NORMAL systolic function


What are the causes of constructive pericarditis?

- Idiopathic
- After cardiac surgery
- Radiation
- Infectious (TB is common)


Describe the clinical presentation of a pt w/ constructive pericarditis

- Elevated JV pressure
- Tachy (very little filling of heart chambers => decreased SV => ^ HR to maintain CO)
- Often w/ hepatomegaly, edema, ascites

Looks like they have chronic liver disease


How do you diagnose constrictive pericarditis?

- Transthoracic echo may see pericardial thickening (maybe calcified)
- MRI or CT can see pericardial thickening
- Cardiac cath shows an early dip and plateau pattern (*square root sign*) during diastole
- Cardiac cath shows equalization of diastolic pressures in RV and LV


Describe the "clinical points" of constrictive pericarditis

- Chronic disease => takes lots of time to develop
- Cardiac silhouette normal sized but encased by thickened pericardium
- Lungs not congested
- Mistaken for liver disease b/c of prolonged high venous pressure => hepatic enlargement and ascites


What is the treatment of constrictive pericarditis?

Surgical stripping of pericardium


What is Kussmaul's sign?

rise in JVP on inspiration